title: Emergent ureteric stent vs percutaneous nephrostomy for obstructive urolithiasis with sepsis: patterns of use and outcomes from a 15-year experience.
abstract: OBJECTIVE
  To characterize the use of emergent JJ ureteric stent placement and percutaneous nephrostomy (PCN) for patients with obstructive urolithiasis with sepsis, and to determine whether outcomes differ between the two treatment methods.
  
  
  METHODS
  A total of 130 patients with obstructive urolithiasis and systemic inflammatory response syndrome criteria were identified retrospectively from a single health system database from 1995 to 2011. Primary outcomes included stone-related and clinical variables which predicted the use of each treatment method. Secondary outcomes included the length of hospital stay, risk of intensive care unit (ICU) admission, and surgical approach used for definitive stone management.
  
  
  RESULTS
  The overall rate of failed procedures was 2.3% (3/130), with one in-hospital death (0.8%). Patients treated with PCN had larger stones (10 vs 7 mm, P = 0.031), and were more acutely ill (acute physiology, age, chronic health evaluation [APACHE] II scores of 15 vs 11, P = 0.036) than those treated with JJ stent placement. Patients treated with PCN were more likely to require ICU admission (odds ratio: 3.23, 95% confidence interval [CI]: 1.24-8.41, P = 0.016), and demonstrated longer length of hospital stay (β: 0.47, 95% CI: 0.20-0.74, P = 0.001), even when adjusting for age, APACHE II score, and Charlson Comorbidity Index score. After resolution of sepsis, patients treated with PCN were more likely to be treated definitively with a percutaneous approach, while patients treated with JJ stent placement were more likely to be treated ureteroscopically.
  
  
  CONCLUSIONS
  Both JJ stent placement and PCN drainage appear effective. Patients with larger stones and who are more acutely ill are more likely to be treated with PCN. Additional randomized clinical trials of adequate power are warranted to define the optimum management of these often complex cases.
authors.affiliation: Division of Urologic Surgery, Duke University Medical Center, Durham, NC 27710, USA.
authors.forename: Zachariah G
authors.initials: ZG
authors.lastname: Goldsmith
authors.forename: Olugbemisola
authors.initials: O
authors.lastname: Oredein-McCoy
authors.forename: Leah
authors.initials: L
authors.lastname: Gerber
authors.forename: Lionel L
authors.initials: LL
authors.lastname: Bañez
authors.forename: David R
authors.initials: DR
authors.lastname: Sopko
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Miller
authors.forename: Glenn M
authors.initials: GM
authors.lastname: Preminger
authors.forename: Michael E
authors.initials: ME
authors.lastname: Lipkin
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006801:Humans; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018805:Sepsis / Q000209:etiology / Q000601:surgery*; D015607:Stents / Q000706:statistics & numerical data; D013997:Time Factors; D016896:Treatment Outcome; D014513:Ureter; D014517:Ureteral Obstruction / Q000209:etiology / Q000601:surgery*; D052878:Urolithiasis / Q000150:complications / Q000601:surgery*; D055815:Young Adult